Insertion of a monitoring electrode for the baby’s heartbeat into the mother via a natural opening.

Code the following procedures.  The first 15 are brief statements of documentation to code for 1 point each.  The last 3 are case studies and are worth five points each.  Partial credit for incorrect codes in the case studies may be given at the discretion of the instructor. There is a total of 30 points possible.  Place your answers in this word document and submit to the drop box when complete.

1.            Insertion of a monitoring electrode for the baby’s heartbeat into the mother via a natural opening.   ________

2.            The nurse changed the monitoring electrode for the products of conception via a natural opening. _________

3.            Acupuncture through skin of right arm, without anesthesia_______

4.            Amniocentesis for diagnostic purposesdone using a percutaneous approach. ______

5.            Low dose rate brachytherapy to testes using Iridium ________

6.            Patient presented to the ER with a non-displaced fracture of the left radius. The ER physician applied a cast to the patient’s left arm.________

7.            The patient was kept on a ventilator for 31 hours after surgery and then extubated.  (Code only the ventilation.) _________

8.            CPR (Cardiopulmonary Resuscitation) was performed on the patient using defibrillation. _________

9.            A patient with ESRD (End Stage Renal Disease) received dialysis.  The dialysis was performed once during the hospital stay for four hours. _______

10.          A patient with suspected obstructive sleep apnea completed a 48 hr. sleep study _________

11.          An anesthetic agent was injected into the right shoulder joint for pain control ______

12.          IM injection of hepatitis A hepatitis B vaccine _______

13.          Vaginal delivery of a baby (products of conception) ______

14.          In Vitro fertilization _______

15.          Plasmapheresis, single treatment _________

Case Study #1

Preoperative Diagnosis:   A 37 week intrauterine pregnancy with a previous C-section.

Postoperative Diagnosis:  A 37 week intrauterine pregnancy with a previous C-section.

Procedure:  Repeat Cesarean section

Operative Report:

The patient was brought in to the operating room and under spinal anesthesia was prepped and draped in the usual manner for a gynecologic abdominal operation.  Through the old suprapubic incision from the previous C section, an incision was made into the abdominal cavity without much difficulty. 

A midline low transverse incision was made at the lower uterine segment with a knife and carried down the uterine cavity without any difficulty.  The incision was then extended to the level of the round ligament on both sides.  A male infant in vertex position was delivered with a vacuum and handed over to the nursery staff in attendance.  Birth weight was 6 pounds 5 ounces.  Apgar was 9 and 9.  Placenta was manually delivered.

The uterine cavity was inspected and found to be normal, irrigated, and then closed by suture.  Hemostasis was verified and found to be adequate.  The abdominal cavity was irrigated and closed in layers.  The pyramidal muscle was closed with suture, the fascia was closed with suture in two halves, and the skin was closed with staples.  The patient tolerated the procedure well.

What is the appropriate ICD-10-PCS code for this procedure?

Case Study #2

Preoperative Diagnosis:  Incomplete spontaneous abortion

Postoperative Diagnosis: Incomplete spontaneous abortion

Procedure:  Dilatation and Curettage

Anesthesia:  IV sedation

Operative Report:

The patient was taken to the operating room and placed in the lithotomy position. She was prepped and draped in the usual sterile fashion.  A weighted speculum was placed in the vagina.  The cervix was adequately visualized.

The cervix was grasped in the anterior lip with a sponge forceps. A considerable amount of placental tissue was present in the vagina and cervix. This was removed without difficulty. A sharp curette was used to obtain a minimal amount of curettings from the endometrial cavity.

The patient tolerated the procedure well.

What is the appropriate ICD-10-PCS code for this procedure?

Case Study #3:

Chief Complaint in the ER:  Alteration of Mental Status

The Inpatient physician ordered an Electroencephalogram to be conducted immediately.

Description:  An 18-channel digital EEG recording was done on the 79 year old male with a chief complaint of alteration of mental status.  The patient is also on insulin for diabetes.

There is a diffuse slowing and disorganization in the background consisting of medium voltage theta rhythm at 4-6 Hz seen from all head areas.  There was faster activity at beta range from the anterior.  Eye movements and muscle artifacts were noted.  Hyperventilation and Photic stimulation were not completed.

Findings:  There is an indication of moderate encephalopathy. Clinical correlation is required to rule out a structural lesion.

What is the appropriate ICD-10-PCS code for this procedure?

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